CDC report chronicles anthrax victims' terrible end

The clinical details, published Friday, paint a grim narrative of the disease, which killed four.

By New York Times,
published November 10, 2001

It took just four to six days after exposure for the first symptoms to appear, usually a mild to moderate fever, drenching sweats and overwhelming fatigue. And once the disease took hold, death, if it occurred, came a day or two later.

The disease was inhalation anthrax, and the 10 patients were among the earliest victims of the nation's first experience with bioterrorism.

On Friday, the Centers for Disease Control and Prevention published the clinical details of these patients, painting a grim narrative of a rare disease but offering few clues to investigators trying to trace the source of the spores or their distribution.

Six of the 10 lived, a much better survival rate than has been reported in the medical literature, which says that inhaled anthrax kills more than 85 percent of its victims.

In a teleconference Friday, Dr. Bradley Perkins, an anthrax expert at the centers, attributed the outcomes to aggressive treatments with antibiotics, drugs to maintain blood pressure, ventilators to aid breathing, and draining fluid that accumulates in the chest.

In interviews on Friday, infectious disease experts said they were fascinated by the cases. Avidly reading about them in a new paper, published online in the centers' journal, Emerging Infectious Diseases, they are searching for clinical and laboratory signs and symptoms that might help them recognize inhalation anthrax and distinguish its early stages from winter colds and flu.

Dr. Marguerite Neill, an infectious disease expert at Brown University, says the case histories tell stories that tables of laboratory tests and reproductions of chest X-rays cannot. "They give you a feeling for the tempo" of the disease, she said.

These specialists looked for risk factors, and characteristics of those who got sick. They noticed that the median age of the 10 patients was 56 and that six had a chronic illness: cardiovascular disease, cerebrovascular disease, diabetes or asthma. But, to the doctors' surprise, none was a smoker.

"That suggests that smoking is not a risk factor for this disease," said Dr. Martin Blaser, an infectious-disease expert at New York University School of Medicine. "I had assumed it would be."

They tried to find something to distinguish those who died from those who survived. The CDC reported that the survivors got antibiotics early. But Dr. Craig E. Smith, the Army's chief infectious disease specialist during the war in the Persian Gulf, said the laboratory tests indicated that those who died actually had more normal values in tests of blood counts and of liver and kidney function than the survivors.

The cases also show what anthrax can look like, what it can feel like and what really happened to those 10 people who make up the statistics. Written in dry medical prose, each case tells a terrifying story of an almost unheard-of disease that took everyone by surprise.

Smith, who is now at the Phoebe Putney Memorial Hospital in Albany, Ga., said he could almost imagine what the patients were thinking, especially as the nation realized that bioterroism had arrived.

"I'm sure every one of them went through a sense of, 'Oh, my God. Is this real or is this just a winter cold?' " he said. Then, as treatment was delayed because the patients or their doctors were slow to recognize the illness, patients may have realized too late that "you're just counting down toward the end of your life the longer you wait for care."

Case 1 set the stage. Robert Stevens, a 63-year-old photo editor in Florida, became ill on Sept. 27, complaining of malaise, fatigue, fever, chills, lack of appetite and sweats. On Oct. 2, he woke up early, nauseated, vomiting and confused.

He was taken to a local emergency room where, the CDC paper reports, "he was not oriented to person, place, or time." Doctors there decided he had meningitis and gave him a collection of antibiotics, but his disease was on a downhill course. He had seizures and was put on a respirator, but died three days later, on Oct. 5.

Case 3 astonished doctors once again, because no one thought that postal workers were at risk of inhalation anthrax. A 56-year-old mail sorter in Washington, whose name the CDC did not release, became ill on Oct. 16, with a low-grade fever, chills, headache, malaise and a sore throat -- one of only two with that last symptom. Each day he got sicker, with a dry cough, night sweats, nausea and vomiting, shortness of breath. On Oct. 19, when he went to the hospital, his heart was racing at 110 beats a minute and his chest X-ray showed that his mediastinum, the area in the middle of his chest, was enlarged, a typical sign of inhalation anthrax.

Anthrax bacteria were in his blood. The man received three antibiotics: ciproflaxcin, rifampin and clindamycin. In the teleconference, Perkins said rifampin might be particularly useful, since it blocks protein synthesis and so might stop anthrax bacteria from producing their deadly toxin.

Patient 3 survived, but did not have an easy course. Three times, doctors drained bloody fluid from his chest. "He remains hospitalized in stable condition," the CDC said.

The final case, Kathy T. Nguyen of New York, is the final surprise, the one person who was neither a member of the news media nor a postal worker. She was a stockroom worker at the Manhattan Eye, Ear and Throat Hospital, and no one knows how or when she became infected; no one has found spores at her home or her work or on her clothing.

Nguyen was admitted to the hospital Oct. 28 and initially diagnosed with congestive heart failure. Then doctors decided she had atypical pneumonia. But as she worsened and was moved to the intensive care unit, doctors saw that her chest X-ray was typical of inhalation anthrax.

They tried everything that was thought to help -- antibiotics, including rifampin and Cipro, draining excess fluid from her chest. But by then nothing could save her. She died Oct. 31.